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Endovascular Thrombectomy and Ischemic Stroke

Saver et al report a meta-analysis of endovascular thrombectomy in ischemic stroke. They reviewed randomized clinical trials of endovascular therapy + medical therapy versus medical therapy alone. The primary end-point considered was functional outcome using modified Rankin score. There was a time dependent benefit that was quantified. There was no effect on mortality. The editorial is available here.

Abstract

IMPORTANCE

Endovascular thrombectomy with second-generation devices is beneficial for patients with ischemic stroke due to intracranial large-vessel occlusions. Delineation of the association of treatment time with outcomes would help to guide implementation.

OBJECTIVE

To characterize the period in which endovascular thrombectomy is associated with benefit, and the extent to which treatment delay is related to functional outcomes, mortality, and symptomatic intracranial hemorrhage.

DESIGN, SETTING, AND PATIENTS

Demographic, clinical, and brain imaging data as well as functional and radiologic outcomes were pooled from randomized phase 3 trials involving stent retrievers or other second-generation devices in a peer-reviewed publication (by July 1,
2016). The identified 5 trials enrolled patients at 89 international sites.

EXPOSURES

Endovascular thrombectomy plus medical therapy vs medical therapy alone; time to treatment.

MAIN OUTCOMES AND MEASURES

The primary outcomewas degree of disability (mRS range, 0-6; lower scores indicating less disability) at 3 months, analyzed with the common odds ratio (cOR) to detect ordinal shift in the distribution of disability over the range of the mRS; secondary outcomes included functional independence at 3 months, mortality by 3 months, and symptomatic hemorrhagic transformation.

RESULTS

Among all 1287 patients (endovascular thrombectomy + medical therapy [n = 634];
medical therapy alone [n = 653]) enrolled in the 5 trials (mean age, 66.5 years [SD, 13.1];women, 47.0%), time from symptom onset to randomization was 196 minutes (IQR, 142 to 267). Among the endovascular group, symptom onset to arterial puncturewas 238 minutes (IQR, 180 to 302) and symptom onset to reperfusionwas 286 minutes (IQR, 215 to 363). At 90 days, the mean mRS scorewas 2.9 (95%CI, 2.7 to 3.1) in the endovascular group and 3.6 (95%CI, 3.5 to 3.8) in
the medical therapy group. The odds of better disability outcomes at 90 days (mRS scale distribution) with the endovascular group declined with longer time from symptom onset to arterial puncture: cOR at 3 hours, 2.79 (95%CI, 1.96 to 3.98), absolute risk difference (ARD) for lower disability scores, 39.2%; cOR at 6 hours, 1.98 (95%CI, 1.30 to 3.00), ARD, 30.2%; cOR at 8 hours,1.57 (95%CI, 0.86 to 2.88), ARD, 15.7%; retaining statistical significance through 7 hours
and 18 minutes. Among 390 patients who achieved substantial reperfusion with endovascular thrombectomy, each 1-hour delay to reperfusionwas associated with a less favorable degree of disability (cOR, 0.84 [95%CI, 0.76 to 0.93]; ARD, −6.7%) and less functional independence (OR, 0.81 [95%CI, 0.71 to 0.92], ARD, −5.2%[95%CI, −8.3%to −2.1%]), but no change in
mortality (OR, 1.12 [95%CI, 0.93 to 1.34]; ARD, 1.5%[95%CI, −0.9%to 4.2%]).

CONCLUSIONS AND RELEVANCE

In this individual patient data meta-analysis of patients with large-vessel ischemic stroke, earlier treatment with endovascular thrombectomy + medical therapy compared with medical therapy alone was associated with lower degrees of disability at 3 months. Benefit became nonsignificant after 7.3 hours.

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